Just Say No: When It Makes Sense Not to Take Your Medicine

The latest comes from a review of studies, published in the Annals of Internal Medicine, that analyzed the effects of a combination of behaviors that reduced the rate of Type 2 diabetes among those at high risk of developing the disease. Making over their diets and boosting their amount of daily exercise, as well as quitting smoking and managing their stress were enough to help the participants, all of whom had high blood-sugar levels that precede diabetes, lower their glucose and avoid getting diagnosed with the disease.

And it’s not the first study to hint at the power of the pharmaceutical-free approach. A study published this month in the journal Cancer Epidemiology, Biomarkers & Prevention reported that brisk walking cut postmenopausal women’s breast-cancer risk by 14% compared with those who didn’t walk. Women who exercised more vigorously enjoyed a 25% drop in risk of developing the disease. Another report in the journal Lancet Oncology found that a plant-based diet, stress management and other lifestyle changes contributed to longer-lived cells among men with prostate cancer. Those results echoed previous work that documented that the same lifestyle-based changes contributed to fewer recurrent tumors among men who had been treated for prostate cancer.

Taken together, the data has more doctors putting away their prescription pads when they see certain patients. The pill-free route isn’t for everyone, however, so it’s important for physicians and patients to understand when it’s appropriate and when it isn’t.

It makes sense, for example, that prescription medications shouldn’t be a first-line treatment for people who are on the verge of developing a condition but can still prevent it — like the participants in the latest diabetes study. Preventing disease is always preferable to treating it, since once symptoms develop, they can cause more complications and additional health issues that require even more drug-based therapies to control. And diabetes is a good example of a disease that can be avoided, with weight management, proper diet and exercise, as the landmark Diabetes Prevention Program, a multicenter trial involving 3,234 people with prediabetes, proved in 2002. In that study, those who changed their diet and exercise habits lost more weight and had a lower rate of developing diabetes than those who took the glucose-controlling medication metformin.

With America’s growing obesity epidemic showing no signs of turning around, understanding how to prevent weight-related chronic disease, such as diabetes, hypertension and heart disease, is even more critical, especially among children, says Dr. David Katz. Katz is the director of the Yale-Griffin Prevention Research Center and author of the new book Disease Proof: The Remarkable Truth About What Makes Us Well. “If you think about the issues that prevail today, they are related to eating too much of all the wrong foods, getting far too little physical activity, toxins we’ve invented like tobacco, inadequate sleep and strained social bonds,” he says.

Treating these ailments with prescription medications can address the symptoms but does nothing to change the forces that drive these diseases. And in some cases, the drugs may cause even more problems, in the form of side effects.

So why aren’t the simpler strategies — exercise and diet changes — as entrenched as the prescription medications? Katz blames muddled messaging. “Unfortunately there has been a lot of bad advice. It has come from people trying to sell products, as well as sound bites and media spin.”

And even good advice, from doctors and public-health officials with good intentions, is often oversimplified to the point where it’s no longer helpful. “Take the ‘just cut fat’ recommendation. What the scientists actually meant was eat more naturally low-fat foods like vegetables. And, frankly, if we had done that, the advice would have been fine. But we didn’t do that, instead we ate low-fat cookies got fatter and sicker,” says Katz. “Essentially what we have done with each attempt to dumb this down is create an opportunity to spin out a whole new set of products that exploit the message.”

And until recently, there hasn’t been much attention paid to what may be driving unhealthy eating — like stress. In the study of men who lowered their risk of recurrent prostate tumors, stress management was part of the lifestyle-based regimen that helped them to keep cancer at bay. Finding a way to address and relieve stress can be an important part of preventing many chronic diseases, says Dr. Dean Ornish, director of the Preventive Medicine Research Institute and clinical professor of medicine at the University of California, San Francisco, who led that study.

According to Dr. Jordan Metzl, a sports-medicine physician at New York City’s Hospital for Special Surgery and author of the upcoming book The Exercise Cure, exercise could be one effective way of coping with stress. And it doesn’t hurt that physical activity also controls symptoms related to heart disease and other metabolic and psychological conditions.

“In my office, I see people from the medical community who are athletic. I see running psychiatrists, running neurologists, running oncologists, cardiologists,” says Metzl. “So I started asking the doctors, What role does exercise play in your treatment of headaches, your treatment of asthma, your treatment of cancer? I found that everyone uses exercise in the care of their patients for both prevention and treatment.”

Granted, Metzl’s patient population may be biased since the doctors he sees already believe in the benefits of physical activity, but he believes more physicians are starting to prescribe exercise as the research to support its benefits continues to grow. “There are studies on exercise and cancer prevention, fatigue, and new neuron formation in the hippocampus,” he says. “There is a nugget for every part of the body from erectile dysfunction, to cancer, to dementia. People are comfortable with the benefits of exercise for obesity or heart disease, but if you look at dementia or anxiety and the data on the role of exercise as prevention and even treatment, it’s amazing how much there is. I think we are seeing a movement toward connecting the dots.”

Doing so will require more than a few enlightened doctors and some scientific data, however. The U.S. health care system is designed to react to disease and treat it once symptoms set in — the reimbursement structure is founded on doctors diagnosing problems and treating them, for example, most often with medications. “The focus of our system is embedded in disease treatment. People make a lot of money off the way it was built, so we give lip service to prevention. But exercise is free.”

At Lincoln Medical Center and Harlem Hospital in New York City, doctors are starting to focus more on prevention by making diet changes a priority for patients — before they find themselves diagnosed with a disease like diabetes or heart trouble. The hospitals have launched the Fruit and Vegetable Prescription, a four-month pilot program, which allows patients with prescriptions — written by their doctors — to get coupons for fresh produce at farmers’ markets and the city’s green carts.

It’s not that prescription medicines aren’t doing their job, or that they don’t have a place in modern medicine. They do, and they are effective in containing disease once they emerge. But if it’s possible to avoid disease altogether, and if patients can do it without expensive medications that can cause complications, why wouldn’t they? Wouldn’t you?